Joan Balcells

Differences in medical therapy goals for children with severe traumatic brain injury-an international study.

Objectives: To describe the differences in goals for their usual practice for various medical therapies from a number of international centers for children with severe traumatic brain injury. Design: A survey of the goals from representatives of the international centers. Setting: Thirty-two pediatric traumatic brain injury centers in the United States, United Kingdom, France, and Spain. Patients: None. Interventions: None. Measurements and Main Results: A survey instrument was developed that required free-form responses from the centers regarding their usual practice goals for topics of intracranial hypertension therapies, hypoxia/ischemia prevention and detection, and metabolic support. Cerebrospinal fluid diversion strategies varied both across centers and within centers, with roughly equal proportion of centers adopting a strategy of continuous cerebrospinal fluid diversion and a strategy of no cerebrospinal fluid diversion. Use of mannitol and hypertonic saline for hyperosmolar therapies was widespread among centers (90.1% and 96.9%, respectively). Of centers using hypertonic saline, 3% saline preparations were the most common but many other concentrations were in common use. Routine hyperventilation was not reported as a standard goal and 31.3% of centers currently use PbO2 monitoring for cerebral hypoxia. The time to start nutritional support and glucose administration varied widely, with nutritional support beginning before 96 hours and glucose administration being started earlier in most centers. Conclusions: There were marked differences in medical goals for children with severe traumatic brain injury across our international consortium, and these differences seemed to be greatest in areas with the weakest evidence in the literature. Future studies that determine the superiority of the various medical therapies outlined within our survey would be a significant advance for the pediatric neurotrauma field and may lead to new standards of care and improved study designs for clinical trials.

Implementing a care bundle approach reduces ventilator-associated pneumonia and delays ventilator-associated tracheobronchitis in children: differences according to endotracheal or tracheostomy devices

OBJECTIVE To reduce ventilator-associated infections (VARI) and improve outcomes for children. METHODS This prospective interventional cohort study was conducted in a paediatric intensive care unit (PICU) over three periods: pre-intervention, early post-intervention, and late post-intervention. These children were on mechanical ventilation (MV) for ≥48h. RESULTS Overall, 312 children (11.9% of whom underwent tracheostomy) and 6187 ventilator-days were assessed. There was a significant reduction in ventilator-associated pneumonia (VAP) among tracheostomized patients (8.16, 3.27, and 0.65 per 1000 tracheostomy ventilation-days before the intervention, after the general bundle implementation, and after the tracheostomy intervention, respectively). The median time from onset of MV to diagnosis of ventilator-associated tracheobronchitis (VAT) increased from 5.5 to 48 days in the late post-intervention period (p=0.004), and was associated with a significant increase in median 28-day ventilator-free days and PICU-free days. Tracheostomy (odds ratio 7.44) and prolonged MV (odds ratio 2.75) were independent variables significantly associated with VARI. A trend towards a reduction in PICU mortality was observed, from 28.4% to 16.6% (relative risk 0.58). CONCLUSIONS The implementation of a care bundle to prevent VARI in children had a different impact on VAP and VAT, diminishing VAP rates and delaying VAT onset, resulting in reduced healthcare resource use. Tracheostomized children were at increased risk of VARI, but preventive measures had a greater impact on them.

Retorno venoso pulmonar total anómalo en pediatría: importancia del diagnóstico ecocardiográfico y de la cirugía precoz

Introduccion y objetivos Estudiamos los pacientes afectados de retorno venoso pulmonar total anomalo intervenidos en nuestro centro. Presentamos la importancia del diagnostico ecocardiografico exclusivo previo a la cirugia. Metodos Desde 1990 hasta 1999, 14 pacientes fueron intervenidos de dicha cardiopatia en nuestro centro. El sitio de drenaje fue en 6 pacientes supracardiaco, 4 infracardiaco, 1 cardiaco (seno coronario) y en 3 pacientes mixto. En 11 casos el diagnostico se realizo por estudio ecocardiografico, siendo los hallazgos corroborados durante la cirugia. Resultados Solo hubo una muerte durante la intervencion quirurgica, relacionada con un ventriculo izquierdo pequeno, y a los 35 dias de la intervencion se produjo otro fallecimiento por sepsis. Durante el postoperatorio inmediato, el control y tratamiento de la hipertension pulmonar fueron los objetivos primordiales. Tras un seguimiento medio de 50 meses, solo un paciente preciso reintervencion; el resto de pacientes se encuentra asintomatico. Conclusiones El diagnostico ecocardiografico de esta cardiopatia puede ser suficiente para indicar la cirugia. Asi mismo la correccion quirurgica precoz del retorno venoso pulmonar anomalo total puede ser realizada con bajo riesgo y buenos resultados a medio plazo.

Association of Ventricular Noncompaction and Histiocytoid Cardiomyopathy: Case Report and Review of the Literature

We report an association between ventricular noncompaction and histiocytoid cardiomyopathy. Both entities are rare, and only 2 cases of their association have been reported previously in the medical literature. Ventricular noncompaction is believed to be caused by an arrest of the normal endomyocardial development, resulting in a thin and compacted epicardial layer and a thickened noncompacted endocardial layer. Histiocytoid cardiomyopathy is a rare arrhythmogenic disorder characterized by aggregates of oncocytic cells involving predominantly the subendocardium. These cells are thought to be abnormal Purkinje cells. In our case, the histiocytoid cells showed strong cytoplasmic expression for the skeletal muscle transcription factor MyoD1, which could be attributed to cross reactivity with an undetermined cytoplasmic antigen.

Pulmonary Interstitial Glycogenosis A Reversible Underlying Condition Associated With D-Transposition of the Great Arteries and Severe Persistent Pulmonary Hypertension

Transposition of the great arteries with intact ventricular septum and persistent pulmonary hypertension (TGA-IVS PPHN) is a rare association with a poor prognosis. We report the case of a term newborn with TGA-IVS PPHN successfully managed with perioperative extracorporeal membrane oxygenation (ECMO) and aggressive pulmonary vasodilation therapy that underwent successful arterial switch procedure. A lung biopsy obtained during the surgical procedure showed pulmonary interstitial glycogenosis, a reversible condition. Concerns over left ventricle deconditioning after ECMO could be minimized with appropriate management and monitoring of the ductus arteriosus and appropriate timing of surgery.

Bedside Ultrasound for the Diagnosis of Abnormal Diaphragmatic Motion in Children After Heart Surgery.

Objective: To assess the utility of bedside ultrasound combining B- and M-mode in the diagnosis of abnormal diaphragmatic motion in children after heart surgery. Design: Prospective post hoc blinded comparison of ultrasound performed by two different intensivists and fluoroscopy results with electromyography. Setting: Tertiary university hospital. Subjects: Children with suspected abnormal diaphragmatic motion after heart surgery. Interventions: None. Measurements and Main Results: Abnormal diaphragmatic motion was suspected in 26 children. Electromyography confirmed the diagnosis in 20 of 24 children (83.3%). The overall occurrence rate of abnormal diaphragmatic motion during the study period was 7.5%. Median patient age was 5 months (range, 16 d to 14 yr). Sensitivity and specificity of chest ultrasound performed at the bedside by the two intensivists (91% and 92% and 92% and 95%, respectively) were higher than those obtained by fluoroscopy (87% and 83%). Interobserver agreement (k) between both intensivists was 0.957 (95% CI, 0.87–100). Conclusions: Chest ultrasound performed by intensivists is a valid tool for the diagnosis of diaphragmatic paralysis, presenting greater sensitivity and specificity than fluoroscopy. Chest ultrasound should be routinely used after pediatric heart surgery given its reliability, reproducibility, availability, and safety.

Prevention of Opioid Withdrawal Syndrome After Pediatric Heart Transplantation: Usefulness of Dexmedetomidine

obesity, and physical inactivity. After decades of efforts to call attention to the disease burden attributable to cardiovascular risk factors, these findings represent an important step toward their complete and critical description. This epidemiological evidence should be expected to direct the debates on the new challenges for maintaining and promoting cardiovascular health in the coming years, as well as specific actions that enable the application of multidisciplinary approaches to the prevention and management of the risk factors and their associated comorbidities. Given the complexity of this issue and the fact that the interactions among the determinants of health vary from one context to another, progress in the attempts to control cardiovascular risk factors will require sustained efforts on a regional, national, and international scale.

Heart transplantation in pediatric patients with pulmonary hypertension.

Patients with congenital heart disease may have pulmonary hypertension secondary to increased pulmonary flow, persistent hypoxemia, or elevated left-side filling pressures. Persistently elevated pulmonary pressure causes pulmonary vasculature remodeling and pulmonary hypertension refractory to vasodilator therapy. Previous reports have described the anatomic-pathologic changes in pulmonary vasculature and their importance. Pulmonary hypertension may be a contraindication for heart transplantation. However, it is difficult to determine the pulmonary resistance value that should be used to contraindicate heart transplantation. Recommendations for pediatric patients are based on experience with adults, and the latest guidelines establish an upper limit of 6 UW/m after the administration of pulmonary vasodilator therapy. Nevertheless, some authors defend the possibility of heart transplantation at higher values. From December 2008 to December 2013, we performed 22 heart transplantations in pediatric patients, among them, 5 patients with severe pulmonary hypertension. The characteristics of these patients are described in the Table. All patients underwent catheterization prior to transplantation, except for 1 patient whose pulmonary pressure was estimated by echocardiography. Pulmonary resistances were calculated at baseline and after the administration of pulmonary vasodilator therapy (nitric oxide). Patient 4 was on the transplantation waiting list for 2 years, but had considerable clinical deterioration with the development of severe pulmonary hypertension (Table); hence, a decision was made to implant a left ventricular assist device and administer pulmonary vasodilator therapy. One month later, the catheterization was repeated and pulmonary resistances had dropped to 3.5 UW/m and, therefore, the patient was put back on the transplantation waiting list. One patient died in the acute phase of the postoperative period due to humoral rejection. All other patients are alive and progressing well. Two patients (40%) required mechanical assistance, 1 due to humoral rejection and the other due to right ventricular dysfunction. All had moderate-to-severe right ventricular dysfunction and required inotropic support and pulmonary vasodilator therapy. In the patients without pulmonary hypertension, right ventricular dysfunction was observed in 9 of 17 (53%; P < .05). Pulmonary vasodilator therapy was maintained at discharge (oral sildenafil), but all patients discontinued the drug during follow-up. Pulmonary biopsies were obtained in 2 patients (Figure) and showed the entire spectrum of vascular lesions characteristic of pulmonary hypertension, with involvement of preacinar and intraacinar arterial vessels, such as plexiform vasculopathy. A venous condition was also observed in the form of hypertrophy. In 1 patient (Figure A), there was a predominance of medial hypertrophy changes in preacinar vessels and plexiform vasculopathy. In the other patient (Figure B), these changes were less serious, but greater intimal thickening was observed, as well as venous involvement with lymph vessel dilation. Comparison of these patients with those without pulmonary hypertension showed no statistically significant differences in survival: 80% of patients with pulmonary hypertension survived compared with 88% of patients without hypertension, with a mean follow-up of 27 (10-62) and 29 (7-60) months, respectively (P > .5). We did observe a higher incidence of cellular (80% vs 24%; P = .02) and humoral (80% vs 12%; P < .01) rejection in patients with pulmonary hypertension, probably due to the greater complexity in this subgroup: 80% of patients with pulmonary hypertension compared with 29% in those without pulmonary hypertension underwent more than 1 cardiac surgery prior to transplantation, including placement of a ventricular assist device (P = .04). Only 2 patients, 1 in each group, had developed antihuman leukocyte antibodies (HLA) before transplantation. In conclusion, it is difficult to establish a value of pulmonary resistance that could be used to contraindicate heart transplantation. Likewise, when referring to pulmonary resistances, the term irreversible should be used with caution because these resistances Rev Esp Cardiol. 2014;67(8):669–679

Asistencia ventricular pediátrica: una realidad asistencial con un futuro alentador

Cada ano aumenta el numero de pacientes pediatricos en lista de trasplante cardiaco. No obstante, el avance de la medicina y de las medidas de prevencion viaria ha modificado el perfil de donantes y ha reducido la oferta de organos pediatricos. La mortalidad en lista de trasplante cardiaco es alta, los tiempos de espera son largos y las opciones de asistir artificialmente a un corazon pediatrico son limitadas comparadas con las del adulto. En Espana, segun datos de la Organizacion Nacional de Trasplantes, durante el ano 2010 estuvieron en lista de espera de trasplante cardiaco 399 pacientes, de los cuales 31 (7,8%) fueron pacientes pediatricos. La mortalidad de los adultos en lista de espera fue del 3,8%, la mas baja desde el ano 1993. En cambio, la mortalidad de los ninos en lista de espera fue del 9,3%, una mortalidad inferior a la de paises como Estados Unidos (19%) pero lejos de las cifras del adulto y, lo que es mas importante, una cifra que apenas se ha modificado en los ultimos anos. En cuanto al trasplante cardiaco urgente se refiere (pacientes en lista de trasplante con dispositivos de asistencia ventricular [DAV] o pacientes en shock cardiogenico que requieren farmacos vasoactivos o ventilacion mecanica), el tiempo en lista para los pacientes

Aprovechando oportunidades y rompiendo barreras para garantizar la traslación del conocimiento basado en la mejor evidencia clínica

The main goal of intensive medicine professionals is to provide appropriate and timely care to patients, especially in the field of paediatrics, where patients have their whole lives ahead of them. To provide quality care to restore health and return the patient to a long and high-quality life. However, despite significant advances in research----there are endless publications----there is a considerable gap between the evidence obtained in clinical research, which demonstrates the benefits of new therapeutic interventions (pharmacological treatment or life support techniques) and the actual impact in patient outcomes of the implementation of these interventions in everyday clinical practice. This gap needs to be addressed, and as health care professionals we must strive to translate the highest-quality evidence from clinical research to the care provided at